AORN J O U R N A L
Intraoperative Cardiac Arrest
NURSINGIMPLICATIONS
Cynthia Brizes Yanick, RN; Sheron Lavery, RN
P reventing cardiac arrest in the operating
room is no longer the sole responsibility
of the anesthesiologist and surgeon. An
operating room nurse who understands the
mechanisms involved in the production of ven-
tricular asystole and ventricular fibrillation and
performs a continuous patient assessment can
respond systematically to alterations in a pa-
tient’s status. Increased knowledge, the use of
hemodynamic monitoring, improved medical
technology, and the expansion of the OR nurse’s
role are helping decrease intraoperative car-
diopulmonary arrest.
Although patients with postmyocardial infarc-
tion or those with any history of cardiac prob-
lems need special preventative efforts, all pa-
tients are at risk for cardiopulmonary arrest in-
traoperatively. By understanding the potential
hazards threatening every patient undergoing
surgery, the OR nurse can be instrumental in the
prevention or treatment of an intraoperative car-
diopulmonary arrest. ’
Two reasons substantiate the belief that the
CynthiaBrims Yanick, RN,BSN, is a clinical level IV
staffnurse at Porter Memorial Hospital, Denver. She
earned her bachelor’s degree in nursing from Ohio
State University, Columbus.
Sheron Lavery, RN, BSN, is clinical manager of the
critical care area at Porter Memorial Hospital. She
earned her diploma in nursing from Mercy Hospital
School ofNursing, Denver, and her bachelor’s degree
from Metropolitan State College, Denver.
Qnthia B. Y
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FEBRUARY 1985, VOL 41, NO 2
OR nurse’s role should include prevention and
intervention skills during cardiopulmonary ar-
rest. First, nurses are responsible for planning
patient care, and they actively participate in the
team effort of prevention and intervention during
cardiopulmonary arrest. The circulating nurse
not only participates in the actual resuscitative
efforts, but mixes and administers resuscitative
drugs. Second, the trend toward outpatient
surgery and the use of only local anesthesia often
render the nurse solely responsible for monitor-
ing the patient during surgery.
Certain variables contribute to cardiac arrest
in some patients. The surgical team should be
alerted to the potential onset of cardiac ar-
rhythmias or arrest during
the passage of endotracheal tubes, particu-
larly in the patient under light anesthesia
and the burn patient
extubation
tracheal suction
downward traction of the stomach or man-
ipulation of abdominal viscera
i RN Sheron Lavery, Rh’
AORN J O U R N A L FEBRUARY 1985, VOL 41, NO 2

Fig 1
Situations Contributing to Cardiopulmonary Arrest
Vagal Stimulation I . Hypoxia
A. Airway manipulation during intubation A. Decreased oxygen supply
B. Gastrointestinal manipulation 1. Lung disease
C. Carotid artery manipulation 2. Anemia
D. Brain stem traction 3. Inadequate oxygenation, eg, airway
obstruction, failure or inadequate
intubation, etc.
B. Increased oxygen demand
1. Tachycardia
2. Shivering

Anaphylactic Allergic Reaction

A. Protamine (shellfish
allergies)
B. Dyekontrast media
C. Blood transfusion
reaction

Hypovolemia I I . Decrease in Cardiac Output

A. Blood loss A. Arrhythmias (secondary or primary)
B. Reduced venous return B , Decreased preload
C. Third spacing 1. Hypovolemia
D. Burns 2. Positional change
E. Dehydration 3. Air embolism
F. Gastrointestinal losses C. Cardiac pump failure
1. Nausea/vomiting 1. Myocardial infarctionhchemia
2. Obstruction 2. Congestive heart failure
3. Diarrhea 3. Cardiac myopathy
4. Nasal gastric suctioning 4. Late septic shock
5. Bowel preps D. Increased afterload
1. Hypertension
2. Increased circulating catecholamines
3. Medications
4. Fluid or blood overload
E. Decreased afterload
1. Vascular hypertension
AORN JOURNAL
manipulation of gallbladder or common
bile duct (sympathetic nerve stimulation)
postural changes such as moving the pa-
tient to cart or onto bed
elevation of kidney rest or turning the pa-
tient during positioning while under anes-
thesia
peritoneal closure (about one third of all
cases occur near the completion of the pro-
cedure and frequently at about the time
traction is being placed under the
peritoneum to allow closure)
operations for strabismus or with pressure
on the eye
surgery on a patient with obstructive jaun-
dice
surgery on a patient with an undue amount
of fear and apprehension
injection of dye during angiography
removal of aortic clamps following surgi-
cal correction of coarctation of the aorta
positioning of cardiac catheter on the out-
flow tract of the right ventricle.2
Almost all currently inhaled anesthetics are
myocardial depressants in varying degrees.
The three profound effects of anesthesia and
surgery on the cardiac system remain cardiac
arrythmias, myocardial depression, and hypo-
tension. A combination of factors, however,
interrelate to induce cardiopulmonary arrest.
Figure 1 demonstrates various situations that
can contribute to cardiopulmonary arrest.
Physiologic Changes
T he immediate result of cardiopulmonary
arrest is hypoxemia. Each organ is sus-
ceptible to hypoxia; the brain is the most
sensitive. An individual loses consciousness
within seconds, and the pupils dilate in 30 to 40
seconds. Irreversible brain damage occurs
within four to six minutes after the arrest.
When the body is adequately oxygenated,
aerobic pathways are used and waste products
are excreted by the lungs. When a cardiopulmo-
nary arrest occurs, anaerobic pathways of
metabolism are used, producing lactic acid as a
byproduct. This accumulation of lactic acid and
FEBRUARY 1985, VOL 41, NO 2
cessation of ventilation with carbon dioxide re-
tention result in severe acidosis. Acidosis de-
presses myocardial contractility, decreases
peripheral vascular tone, and interferes with
catecholamine production and action.
Cardiopulmonary resuscitation (CPR) main-
tains minimal oxygen supplies to the body until
definitive correction is taken (ie, defibrillation,
medications, pacemakers). Acidosis must be
treated first by ventilating the patient and then by
administering sodium bicarbonate intrave-
nously.
In most circumstances, the patient undergoing
cardiopulmonary arrest in the operating room
may have some distinct advantages in relation to
resuscitative efforts. During the most vulnerable
periods of surgery the patient’s heart rate and
rhythm are being monitored, and the patient has
an intravenous infusion already in place. The
patient may be intubated (or intubation supplies
are near), and the members of the surgical team
including the surgeons, anesthetists, nurses, and
technicians are aware of the patient’s previous
vital signs and are available for immediate inter-
vention. Despite all these elements of control, an
intraoperative cardiac arrest can occur.
Cardiopulmonary arrest during surgery can
present symptoms along a broad spectrum. The
subtle, undetected changes occur more often
than the dramatic, sudden onset of arrythmias,
respiratory arrest, and cardiac standstill. In-
traoperatively , a patient’s physiological and
psychological responses are altered because of
preoperative medications, underlying pathologic
conditions, anesthetic agents and levels, and
stages of fluid and electrolyte imbalances. The
influences of the autonomic nervous system can-
not be underestimated (see “Autonomic Nerv-
ous System”). These variables mask a patient’s
response to impending cardiac arrest and alter
the patient’s intrinsic mechanisms to cope with
physiologic insult. During surgery or during pa-
tient transport to and from surgery or the recov-
ery area, the detection of impending arrest may
be delayed because the patient is concealed
under the surgical drapes. Detecting impending
arrest may be difficult because the patient ap-
pears to be sleeping from the effects of the pre-
AORN JOURNAL
Table 1
Positioning to Maintain Cardiovascular Homeostasis
Positiodphysiologic response
Supine
Decrease in blood pressure, heart rate, and
peripheral resistance, especially during
induction of anesthesia.
Venous pooling in extremities due to
reduction of venous pressure.
Prone
Venous pooling in extremities because of
reduction of venous pressure.
Pressure on great vessels because of improper
positioning, reducing venous return.
Increase in central venous pressure,
increasing surgical venous bleeding.
Pressure on carotid sinus can cause
hypotension and arrhythmias when head is
turned to the extreme left or right.
Positioning devices are used to immobilize
the head, neck, or shoulders.
Diminished blood flow to any portion of head,
especially eyes, ears, nose, or lips due to
excessive pressure.
Head Elevated Position
Venous pooling in extremities because of
reduction of venous pressure.
Hypotension due to hypovolemia is more
difficult to compensate for while in upright
position and can add to circulatory insult.
~~ ~~~~~
Adapted from Advanced Cardiac Life Support (American Heart Association, 1981) V l l l 1-16.
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FEBRUARY 1985, VOL 41, NO 2
Nursing activity
Apply ECG electrode.
Provide anesthesia with adequate fluid
replacement pm.
Elevate lower extremities slightly to aid in
venous return. (Do not place in
Trendelenburg’s position.)
Insert urinary catheter to assess renal perfusion
Pm.
Apply antithromboembolism hose or bandages
Prn.
Position patient on chest rolls so the abdominal
contents hang freely.
Prevent hyperextension of the neck, especially to
the extreme right or left.
Avoid pressure on carotid sinus, especially when
using immobilizing devices.
Provide supporting, positioning devices that will
alleviate pressure, eg, donuts, foam, head
rests.
Prevent any pressure on eyes.
Provide adequate fluid replacement with
anesthesia. Assess blood loss and urine output
continuously.
FEBRUARY 1985,VOL 41, NO 2
Monitoring and evaluation
Monitor blood pressure by cuff or invasive
technique.
Monitor ECG for rate and rhythm pm.
Observe for signs of inadequate tissue perfusion,
eg, cyanosis, edema, mottling, clammy skin.
Monitor urine output and maintain at 30 cc to
60 cc per hour minimum.
Observe lower extremities for edema. Prevent
rolling of hose or bandages to produce a
tourniquet effect.
Ask patient about comfort of the hose, wraps, or
elevation of extremities.
Assess abdomen after positioning to determine if
there is excessive pressure.
Monitor central venous pressure if applicable.
Assess patient for pressure points before
draping.
Assess head position and maintain in good
anatomical alignment.
Monitor blood pressure and ECG.
Assess head structures for pressure, diminished
perfustion, etc.
Maintain fluid input.
Monitor ECG, blood pressure, and central
venous pressure prn.
AORN JOURNAL
Resuscitative actions
Quickly conceal surgical incision with a sterile
drape or towel if needed.
Expose chest before initiating CPR to locate
lower third of sternum.
Lower operating room table to the lowest resting
position.
Provide the resuscitator with a standing stool to
maximize the effectiveness of cardiac
compressions.
Initiate CPR.
Assess and maintain airway status.
Recruit staff to assist with turning the patient to
supine position either on OR table or a
guerney .
Quickly conceal surgical incision with a sterile
drape.
Follow resuscitative actions in supine position.
When patient is in a suspensory positioning
device, disconnect these devices supporting
the head, neck, and upper torso.
Reposition the OR table and attachments to
accommodate supine patient.
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FEBRUARY 1985,VOL 41, NO 2
Autonomic Nervous
System
Parasympathetic System
The vagus nerve is the 10th cranial nerve
and is cardioinhibitory. Stimulation of the
vagus nerve releases the neurotransmitter
acetylcholine and causes decreased firing of
the sinoatrial node, decreased contractility of
the atria (and probably the ventricles) and
impairment of conduction through the
atrioventricular node. The vagus nerve can
be stimulated by reflexes of fear and pain,
by increased pressure in the aortic arch
and/or carotid arteries, and by the reflex
pathways located in the respiratory and
gastrointestinal tracts. These pathways take
on significance considering the numerous
maneuvers and procedures done during the
operative procedures, ie , intubation,
strabismus or pressure on the eye,
manipulation of the stomach, gallbladder, and
intestines. Stimulation of the vagus can cause
cardiac arrhythmias, cardiac asystole or
circulatory collapse.
Sympathetic System
Sympathetic spinal nerve fibers innervate the
entire heart. The postganglionic
neurotransmitter of the sympathetic nervous
system is norepinephrine. Sympathetic
responses cause a release of norepinephrine,
which results in an increased heart rate,
contractility, and cardiac electrical
conduction. There are many reasons why
patients undergoing surgery experience
sympathetic response including psychological
and physiological stress (ie, intubation,
median sternotomy, joint manipulation).
Note
1. Andreoli, Kathleen Gaynor, et al, Com-
prehensive Cardiac Care (St Louis: C V Mosby
Company, 1983) 8.
AORN JOURNAL
operative medication.
When impending or actual cardiac arrest has
been diagnosed, intervention may be compli-
cated by variables intrinsic to the operating
room.
Patient position. The patient should be placed
in a horizontal supine position for CPR to be
effective. Resuscitative efforts can be hindered
by certain patient positions required during
surgery. Although these positions are unavoid-
able, a plan for intervention should always be a
primary consideration. Treating patients in
prone, sitting, or lateral positions can be a com-
plicated effort (Table 1). Turn the prone or lat-
erally positioned patient to the supine position,
either axially on the operating room table or onto
a guerney. With an open incision, quickly apply
a sterile towel or adhesive drape before turning
the patient to the supine position. If the patient is
in the sitting position, head prongs may need to
be dislodged. Head and neck support needs to be
maintained, and a table extension must be at-
tached to accommodate the upper torso. Other
positioning variables restricting resuscitative ef-
forts include kidney rests or braces, overhead
armboards, extensive use of tape, ie, across hips
and shoulders in the lateral position, a patient
positioned on a fracture table or on a deflated
bean bag, or a patient in a full body spica cast.
Environmental factor. Maintaining access to
the patient should remain a high priority
throughout the operation. The immediate re-
sponse to the arrest should not be hindered by
obstructive equipment, furniture, carts, x-ray
machines, or jammed doorways. There should
be a clear pathway to the entrance of the indi-
vidual operating rooms for responding personnel
and the crash cart. Make the crash cart accessible
to all employees and store it in a standard visible
location Fable 2). Floors should be dry. Spilled
solutions, pieces of debris, and supplies should
never be allowed to accumulate on the floors;
these can cause employees to trip or fall during
their accelerated pace. Most operating room ta-
bles can only be lowered to a certain point.
Effective CPR cannot be performed on the pa-
tient positioned on the operating room table un-
less the resuscitator is elevated on a standing
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A O R N JOURNAL FEBRUARY 1985, VOL 41, NO 2

Table 2
Equipment, Supplies and Medications
for Crash Cart
Equipment Monitoring supplies
Cardiac oscilloscope with recorder 2 packages of four monitoring gel pads
Defibrillator 5 packages of single monitoring gel pads
2 complete sets of monitoring electrodes
Drugs ECG electrode tester
4 adrenalin 1:10,OOO with intracardiac needle extra ECG paper
10 cc Nasogastric sump tube with connector and
2 aminophylline 500 mg-20 cc 50 cc irrigating syringe
2 atropine 1 mg-10 cc
2 calcium chloride 1 g-10cc Airway supplies
1 50% dextrose-50 cc ampules suction machine
6 sodium bicarbonate 50 meq-50 cc two 14-gauge suction catheters
ampules glove sets with Hz0
4 lidocaine hydrochloride 100 mg-10 cc tonsil suction
1 bretylium 500 mg-5 cc one 10 ft connecting tubing
2 norepinephrine (Levophed) 4 mg
a m p u l e s 4 cc Endotracheal intubation equipment
3 propranolol (Levophed) (Inderal) 1 mg endotracheal tubes (soft cuff),
ampules-1 cc sizes 7, 8, 9, and 10
1 dopamine hydrochloride 400 mg laryngoscope blades:
1 isoproterenal (Isuprel) 2 mg-10 cc curved blades-sizes 3, 4
2 naloxone hydrochloride-1 cc straight blades-sizes 3, 4
1 lidocaine 2 gm laryngoscope battery pack
spare bulb and two spare
Intravenous supplies C-cell batteries
2 250 cc D5W forceps
2 pediatric drip IV administration sets guidewire
1 IV extension tubing one 12 cc syringe
2 subclavian catheter sets one hemostat with padded clamps
2 18-gauge teflon venous cannulas adhesive tape, 1 inch
2 20-gauge teflon venous cannulas bottle local endotracheal anesthetic
tourniquet small bottle tincture of benzoin
povidone iodine swabs one extra sterile endotrachael tube
tape, ?hinch and 1 inch adaptor
medication labels
povidone iodine sponge sticks Arterial blood gas kits
syringes (two 12 cc, 6 cc, and
1 glass 10 cc syringe) Miscellaneous
disposable razor flash1ight
three 20 cc gauge 1 inch needles defibrillating sponges
three 3 cc disposable syringes, 1 inch needles antiseptic spray (eg, betadine)

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AORN J O U R N A L FEBRUARY 1985, VOL 41, NO 2

stool.
The operativefield. During cardiac arrest, the
surgical team may not be able to maintain asep-
sis. Initiating CPR and administering definitive
therapy holds precedence over isolating an open
wound. The onset of arrest can lead to immediate n
death if treatment is delayed, whereas treating
infection can be pursued when the patient’s con-
dition has been stabilized. An open wound can
be easily and quickly concealed during the resus-
citative efforts by applying a sterile towel, sheet,
gown, or adhesive drape. If hemorrhage is a
problem, designate one person to monitor and
control hemostasis during the resuscitative ef- Make CPR reviews mandatory for all
forts. personnel.

What Not To Do

D o not delay in learning and relearning

cardiopulmonary resuscitation tech-
niques. Biannual CPR reviews for all
OR personnel should be mandatory. Periodic
stimulated resuscitations in the operating room
add to the reviews. Each staff member must keep
skills current and identify educational needs for
themselves.
Do not limit cardiopulmonary resuscitation
training to just registered nurses. Anyone who
has patient contact should be skilled in resuscita-
tion techniques including operating room techni-
cians, orderlies, ward assistants, and environ- Do not panic, start CPR.
mental services personnel. It takes a team to
successfully resuscitate a patient; every person
has an important role to play.
Do not panic. While this is an emergent situa-
tion, take a deep breath and remember what you
learned in your basic training and simulated situ-
ations.
Do not forget to call for help. Do not aban-
don the patient. Summon help by pushing an
emergency button, using an intercom, alerting a
passer-by , or yelling.
Do not be fooled by preoperative medicated
patients who appear to be sleeping. Patients
who have been preoperatively medicated are
subject to cardiac or respiratory arrest. An un- Detecting arrest can be difficult if patient
witnessed, unrecognized arrest wastes precious appears to be sleeping from preoperative
moments. medication.

418
FEBRUARY 1985,VOL41, NO 2
Do not waste time trying to troubleshoot
monitoring equipment when the patient ar-
rests. When the patient’s electrocardiogram or
pressure tracing changes, quickly assess the pa-
tient’s pulse rather than assuming the equip-
ment is at fault.
Do not delay CPR to protect the sterile
field. The conditioned response that nurses have
to protect the sterile field must be modified.
Quickly cover the incisioned site with sterile
towel or drape, position the patient in the supine
position, and begin CPR.
Do not give too much bicarbonate. Sodium
bicarbonate can overload patients with fluid and
sodium. Bicarbonate causes alkalosis, which is
as dangerousas acidosis. Alkalosis binds oxygen
to the hemoglobin, which means that the oxygen
will not be released to the cells and the problem
of cellular ischemia is compounded. Alkalosis
causes potassium to shift into the body’s cells
resulting in hypokalemia. Excessive bicarbonate
administration causes rapid diffusion of carbon
dioxide across the blood brain barrier, causing
cerebrospinal acidosis, resulting in postresusci-
tation cerebral dysfunction.
Do not forget to documentthe resuscitation
efforts. Assign a recorder to document the pa-
tient’s responses, team’s efforts, and treatment
intervention. Attempts to draw arterial blood
gases or intubate the patient should be
documented even if they are unsuccessful.
Do not hesitate to order unnecessary per-
sonnel out of the room.Identify essential per-
sonnel and dismiss all others. 0 6. Health maintenance and preferred
Notes
1. J Kneedler, G Dodge, Perioperative Patient
Care (Boston: Blackwell Scientific Publications, Inc,
1983).
2. H E Stephenson,Cardiac Arrest and Resuscita-
tion (St Louis: C V Mosby Company, 1974) 35.
3. Ibid, 336.
4. Gayle Gatch, “Cardiac Arrest in the OR,”
AORN Journal 32 (December 1980) 983.
Suggested readings
Martin, John T. Positioning in Anesthesia and
Surgery. Philadelphia: W B Saunders Co, 1978.
Snow, John C. Manual ofAnesthesia. Boston: Little,
Brown, and Co, 1980.
AORN JOURNAL
Staff Cuts Reported
in Most Hospitals
There are wide staff cuts in most of the
nation’s hospitals, reports the American
Journal of Nursing in the August issue.
Nursing and hospital association executives
were used for a telephone survey in 15
states. The survey showed that all states
except New York had staff reductions in the
past year. Many of the hospital directors
were stunned by the sudden drop in business,
forcing them to cut staff.
The survey showed six factors contribute
to the lowered hospital censuses.
1 . Unemployed workers, who have lost
health insurance, are postponing
treatment.
2. Businesses, rebelling against high cost
of insurance, are making employees pay
more out of pocket money for care.
3. Blue CrosdBlue Shield is cracking
down by requiring utilization reviews,
by tailoring benefits toward outpatient
clinics, by sponsoring more health
maintenance organizations, and by
starting its own DRG-based schemes.
4. Outpatient centers and hospitals are
competing for same-day-surgery
patients.
5 . Because Medicaid is also looking at
DRGs, states are putting ceilings on
Care.
provider organizations are undercutting
fee-for-service care.
421