Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
When a patient experiences cardiovascular or respiratory collapse in the operating room (OR), rapid recognition, coordinated intervention, and immediate access to appropriate equipment and personnel are essential. Although cardiac arrest during anesthesia is uncommon, particularly during outpatient surgery, the severity of the situation means that OR teams must all be prepared and trained to perform emergency resuscitation. Factors such as airway obstruction, respiratory depression, severe hypotension, hemorrhage, and adverse drug reactions may cause arrest. Unlike cardiac arrests occurring outside healthcare facilities, perioperative emergencies are generally witnessed, with continuous physiological monitoring and information about potential precipitating factors available to guide treatment [1,2]. However, unlike the hospital setting, the outpatient OR generally does not have access to intensive care monitoring or certain equipment.
When cardiac arrest occurs, effective chest compressions, adequate ventilation, and early defibrillation for shockable rhythms are essential. High-quality cardiopulmonary resuscitation (CPR) requires a compression rate of 100–120/min to a depth of approximately 5 cm in adults, with complete chest recoil and minimal interruptions. Excessive ventilation should be avoided because increased intrathoracic pressure can reduce venous return and compromise coronary and cerebral perfusion [1,3].
However, perioperative cardiac arrest differs from conventional cardiac arrest in both etiology and management. Potential causes include anesthetic-induced cardiovascular depression, hypovolemia, hypoxemia, high neuraxial blockade, local anesthetic systemic toxicity (LAST), and anaphylaxis. Traditional advanced cardiovascular life support (ACLS) algorithms should be adapted to address these reversible causes. Initial management involves calling for assistance, stopping the procedure, reducing or discontinuing anesthetic administration when appropriate, administering 100% oxygen, and evaluating airway patency, ventilation, and circulation [2].
Airway and respiratory emergencies are particularly relevant in outpatient anesthesia, where sedation and supraglottic airway techniques are frequently employed. Airway obstruction, hypoventilation, and inadequate oxygenation can rapidly progress to cardiac arrest if unaddressed. In a retrospective study of 518,294 anesthetics, Sprung et al. identified 24 anesthesia-attributable cardiac arrests, of which 11 were associated with airway or ventilation problems. Immediate airway assessment, effective positive-pressure ventilation, and escalation to advanced airway management when necessary are therefore essential [4].
Anaphylaxis is another perioperative emergency in the outpatient OR that may require emergency resuscitation. It may present with sudden hypotension, bronchospasm, or cardiovascular collapse, sometimes without cutaneous manifestations. The Resuscitation Council UK recommends early intravenous adrenaline and rapid crystalloid administration. For adults and children older than 12 years, an initial intravenous adrenaline dose of 50 micrograms is recommended, titrated according to response. Persistent instability may require an adrenaline infusion, while cardiac arrest necessitates immediate CPR [5].
Certain perioperative situations require specialized resuscitation strategies, such as LAST or cardiac arrest in patients positioned prone. LAST uses lipid emulsion therapy to reduce local anesthetic in circulation and requires reduced adrenaline dosing. Although prone CPR has demonstrated the ability to generate circulatory pressure in experimental studies, evidence remains limited, and conventional supine CPR remains the standard when feasible [3,6].
Emergency resuscitation preparedness is particularly important in outpatient facilities, where advanced critical care resources may not be immediately available. Emergency equipment, defibrillators, airway supplies, resuscitation medications, and established transfer protocols should be readily accessible. Regular simulation training and clearly defined team responsibilities support coordinated responses to rare but critical events [2,6].
Following successful resuscitation, continued monitoring and transfer to inpatient care may be necessary. Effective emergency resuscitation in an outpatient OR depends on early recognition, high-quality CPR, identification of reversible causes, and coordinated multidisciplinary intervention.
References
- Cooper JA, Cooper JD, Cooper JM. Cardiopulmonary resuscitation: history, current practice, and future direction. Circulation. 2006;114(25):2839–2849. doi:10.1161/CIRCULATIONAHA.106.610907.
- Moitra VK, Einav S, Thies KC, et al. Cardiac arrest in the operating room: resuscitation and management for the anesthesiologist: part 1. Anesth Analg. 2018;126(3):876–888. doi:10.1213/ANE.0000000000002596.
- Wei J, Tung D, Sue SH, Wu SV, Chuang YC, Chang CY. Cardiopulmonary resuscitation in prone position: a simplified method for outpatients. J Chin Med Assoc. 2006;69(5):202–206.
- Sprung J, Warner ME, Contreras MG, et al. Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: a study of 518,294 patients at a tertiary referral center. Anesthesiology. 2003;99(2):259–269.
- Dodd A, Turner PJ, Soar J, Savic L. Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists. Anaesthesia. 2024;79(5):535–541. doi:10.1111/anae.16206.
- Smith Z. Editorial: cardiac arrest in the operating room: reevaluating advanced cardiovascular life support. APSF Newsletter. 2025;2:44–45.