Responding to Cardiac Arrest

By Patricia Woolson, RN, MSN

2.0ANCC/AACN CONTACT HOURS

A calm yet stern voice booms over the intercomsystem of the OR, “anesthesia stat to room two,anesthesia stat room two.” As the nurse in thenext room, you can’t help but think, what hap-pened? What case is it? Is there enough help? A team of five OR providers grows to nine.

Cardiac arrest in the OR is uncommon,excluding trauma and critically ill patients. Formost OR personnel, except open-heart surgerystaff, cardiac arrest is unplanned and unexpected.

Cardiac arrest is the result of severe cardiovas-cular and/or respiratory insult, which may occurat any time during the perioperative period.Cardiac arrest is the sudden cessation of heartfunction, resulting in death if the patient isn’tsuccessfully resuscitated in a timely manner.1

Cessation of cardiac action occurs, and thepumping mechanism of the heart ceases to function.2 Cardiac arrest is the endpoint of dysrhythmias, cardiac pump failure, hypoxemia,sepsis, hemorrhage, drug toxicity, and metabolicdisturbances.3

According to the American Society ofAnesthesiologists (ASA), because of improvedpatient monitoring and safer anesthetic agents, cardiac arrest during anesthesia is a rare occur-rence. Intraoperative cardiac arrest affords each

Although uncommon,

OR personnel must be prepared

to handle a cardiac arrest in a timely manner.

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cardiacarrest

Responding to

32 OR Nurse2007 May/June www.ORNurseJournal.com

patient an immediate response. There’s little or nodelay before corrective actions are initiated within thesurgical setting.4 According to the American HeartAssociation, response time is critically important to the patients’ outcome. Prompt initiation of resuscita-tive actions may delay any further deterioration ofneurological or ischemic effects.

Etiology Factors that contribute to cardiac arrest during thisperiod include difficult airway management with subsequent hypoxia, and hyperkalemia, hypovolemia,anesthetic effects, adverse drug effects, myocardial

infarction, and exsanguination due to trauma (seePossible causes of cardiac arrest).2 Other factors that maypredispose surgical patients to cardiac arrest are critical-ly ill patients, emergency surgery patients, and thosewith compromised cardiac and respiratory function.

The ASA physical status classification is an assess-ment tool used to determine the patient’s condition at the time of surgery. Patients deemed an ASA III or higher are at greater risk (see ASA physical statusclassifications).5

EducationOne of the most critical elements in preparation for a

Cardiac arrest

Possible causes of cardiac arrest2

Below is a list of some of the potential factors that may contribute to cardiac arrest in the OR. Promptdiagnosis and treatment may prevent cardiac arrest, but if it does occur, initiate CPR and follow ACLS orPALS guidelines as appropriate.

Possible causeHypoxia associated with difficult airway management, dif-ficult intubation, obstruction dueto trauma

Extreme blood loss

Electrolyte imbalance, history of coronary disease, adversedrug reaction to anestheticagents, acidosis

Hyperkalemia related to chronickidney disease, metabolic acidosis, adverse drug reactionto ACE inhibitors, succinyl-choline, potassium supplementor potassium-sparing diuretictherapy

SymptomsHypoxemia: Initially, patientmay exhibit tachycardia andtachypnea. Prolonged hypox-emia may result in hypoxia andcardiac dysrhythmia, renal, liveror heart damage, and cardiacarrest may occur.

Hypovolemia may result inhypotension, tachycardia,tachypnea, oliguria, shock, orcardiovascular collapse.

Dysrhythmias: bradycardia,supraventricular tachycardia,ventricular tachycardia, or ventricular fibrillation, if notsuccessfully treated, results in cardiac arrest.

Serum potassium level isgreater than 5.5 mEq/L (perfacility laboratory standards).Patients with hyperkalemia mayexhibit muscle weakness, flaccid paralysis, ECG changesincluding tall, peaked T-wavesand widened QRS complex, andif hyperkalemia is left untreated,may result in cardiac arrest.

InterventionMaintain patent airway andincrease oxygenation via bag-valve mask, laryngeal mask airway, or possibletracheotomy.

Replace fluid loss and blood volume with crystalloids, colloids, or volume expanders.

Administer antiarrhythmics, perform cardioversion or defibrillation as appropriate based on heart rhythm.

Treatment determined by patient’scondition. Stop any administrationof potassium; may need to administer loop diuretics, and regular insulin I.V. with hypertonicdextrose to move potassium ionsinto the cells. Calcium chloride or calcium gluconate can be used toreduce myocardial effects ofhyperkalemia and prevent ventricular fibrillation.


cardiac arrest in the OR is staff education. As nursingprofessionals, we need consistent, ongoing education.Perioperative educators must continue to pursueavenues to enhance the staff’s knowledge base in avariety of clinical situations, including cardiac arrest.Perioperative nurses and nonlicensed OR personnelshould be trained in basic life support (BLS).

Advanced cardiac life support (ACLS) training isencouraged. ACLS concentrates on the intricacies ofmanaging cardiac arrest as it relates to identificationand control of dysrhythmias, medication administra-tion, and use of adjunctive equipment and monitoring.In ORs that care for pediatric patients, pediatricadvanced life support (PALS) is also encouraged. PALStraining incorporates all the elements of ACLS butwith a pediatric focus. Minimally, nurses should attendthese classes every 2 years, however some facilitiessupport a yearly refresher course. As professionals, thestandard of practice indicates that nurses must assumeresponsibility for their ongoing education.

Education related to emergency situations includesstaff participation in ACLS and PALS programs. Nursesneed to stay current in standards of practice and stayabreast of advances in emergency care technique.

The ideal follow-up to BLS and ACLS training is toconduct “mock codes.” Mock codes allow the staff tobecome proficient in emergency procedures.Educators and clinical nurse specialists present scenar-ios for the staff to actively demonstrate their responsein an emergency situation. The educator or observernotes the timeliness of staff response, the order ofevents, the process of assessing factors, which mayadversely affect the patient, and the staff’s ability toarticulate the process. Validation of competence foreach staff member should be completed during amock code. The importance of each of the followingmust also be addressed:• repositioning the patient before compressions canbe attempted• closing or packing the wound (with patient in different positions) before resuscitative efforts can beinitiated• transferring the patient to a stretcher or bed with different incision types• disconnecting any equipment attached to the patient• removing all instrumentation (such as retractors) thatcould interfere with CPR• preventing fire in the OR by securing lasers andelectrosurgical units and removal of oxygen sourcefrom the patient prior to defibrillation.

Whether mock codes are practiced monthly orquarterly, staff should be prepared for a cardiac arrestsituation. Other learning opportunities include scav-enger hunt exercises with the emergency carts (crashcart, malignant hyperthermia cart, and PALS cart) anddemonstration of ability to appropriately operate thedefibrillator. The objective is to learn not only what’son the cart but where it’s located.

AORN’s standards and recommended practicesindicate that education is an integral part of maintain-ing patient safety.6 Educators must consistentlyaddress the needs of the staff regarding performanceof CPR, emergency medication administration andother adverse events.

Other educational considerations include under-standing equipment and alternate positioning. The following operating tables or positions need to bereviewed:• prone position

ASA physical status classifications5

During the preanesthesia visit, the anesthesiolo-gist completes the anesthesia evaluation andassigns the patient a numerical value according to the ASA Physical Status Classification. This classification system is used to determine thepatient’s condition at the time of surgery. Thehigher the number, the greater the patient’s riskunder anesthesia.

ASA Indicator1

2

3

4

5

6

DefinitionsNormal healthy patient

Patient with mild systemic disease (type 2 diabetes, well-controlled asthma, hypertension)

Patient with severe systemic disease that’s limiting but notincapacitating

Patient with incapacitating disease that’s a constant threatto life

Patient not expected to survivewithout surgery

Patient declared brain dead whois undergoing organ removal fororgan donation

• fracture tables• beach-chair position• Jackson table.

Competency validation in positional equipmentshould be performed at least annually.

Evidence-based practiceNursing research states that 84% (54/64) of patientsexhibit at least one behavioral change and/or have anew complaint in the 8 hours preceding cardiacarrest.7 This study also noted that physiological abnor-malities are present in as many as 90% (58/64) of thepatients in the 8 hours preceding an adverse event(AE). These behavioral and physiological abnormalitiesare respiratory and/or circulatory dysfunction; identi-fied changes were tachypnea, bradypnea, hypoxemia,tachycardia, bradycardia, hypotension, and hyper-tension.6 During the preoperative interview, the circulating nurse should assess the patient and askquestions regarding these indicators:• headache• heart palpitations• increased heart rate • shortness of breath• indigestion• chest discomfort• edema• dizziness

Additional “red flags” are any history of difficultintubation, malignant hyperthermia, past anesthesiaproblems, or history of cardiac disease. The circulatingnurse has so little time with patients that every interac-tion is a valuable opportunity to elicit information.Communication with the surgical team is essential toaddress any changes the patient may have recentlyexperienced.

Staff responsibilitiesOrganization and preparation may contribute to apatient’s favorable outcome. Staff member’s uncertain-ty of the appropriate procedure will bring chaos to an already critical situation.

The surgical team must be familiar with theirresponsibilities as this will impact their performanceduring the code. Every member of the surgical teammust be prepared to respond quickly and efficiently.Roles and responsibilities include2:

Code director. This is usually the anesthesiaprovider’s responsibility, but if an arrest takes placeduring a local case, the surgeon would assume this

role. This individual runs the code and directs codeactivity. During this time, personnel are directed toretrieve necessary equipment and/or medications. Asresuscitative interventions are implemented, all surgicalteam members are expected to participate.

Circulating nurse. Activates the call for the codeaccording to facility guidelines. The circulator performsthe following actions according to the level of activityand assistance available in the surgical suite:• records time of arrest• retrieves the crash cart if alone, otherwise first-linemedications are available in the anesthesiologist's cart• assists in repositioning the patient and the OR tableto facilitate CPR. May direct others to remove equip-ment from the room if it interferes with successfulresuscitation.• notifies the OR manager/charge nurse of emergencyand requests assistance, including but not limited toanesthesiologists, intensivist, pharmacist, anesthesiatechnicians, RNs, and PACU personnel• controls traffic in the room (directs visitors/students from the room)• maintains the accuracy of the instrument, spongeand needle counts with specific attention to woundclosure if in progress • assists in maintaining the integrity of the sterile field.It’s important to note that resuscitative efforts are para-mount to the security of the sterile field • delegates tasks to other personnel as necessary• documents all activities in the room (time, dose, andfrequency of all medications administered, route, andwho administered them) in order of occurrence• performs compressions as needed until support per-sonnel are available• follows facility guidelines for family notification ifCPR attempts are unsuccessful, care of the body, spec-imen care and documentation of the death and dispo-sition of the body.

Scrub person. Maintains personal sterility and thesterile field. In the event of noncardiac surgery (wherethe chest isn’t open), prepares for packing of the surgi-cal wound with saline-soaked sponges and covers withsterile drape. The scrub person also performs the fol-lowing:• assists in repositioning the patient for initiation of CPR• gives total attention to surgical field and surgeon’sneeds related to bleeding, suctioning, and/or woundclosure• assists as required in the event the circulator is other-wise occupied.


Cardiac arrest


Surgeon. Closes wound if needed, assists in resus-citative activity (performs compressions, assists in repo-sitioning patient), and leads code in non-anesthesiacase. Administers medications as needed.

OR manager/charge nurse. Assigns personnelto assist the surgical team (extra circulator, personnelto handle supplies or lab work) as needed. Notifiesthe ICU and house supervisor of potential admission.Also responsible for:• revising schedule as situation dictates• monitoring and assessing emergency procedure andstaff performance• supporting the team as required• supporting the surgical team in a cardiac arrest event.

Physician assistants, residents, and regis-tered nurse first assistants (RNFAs). These indi-viduals should assist as directed by the code leader/anesthesiologist and assist the circulator as needed.

Appropriate documentation during an emergencyevent is crucial. Information noted during adverseevents must be complete, concise, and factual. Codeforms are maintained on the crash cart to facilitateeasy access. Documentation during a cardiac arrestmust include several critical elements. This data isdetermined by the institution and staff need to befamiliar with its content. The information recorded istime sensitive and minimally includes:• patient label/identification per facility• time of arrest• name of all surgical team members or participants• diagnosis• presence of endotracheal (ET) tube, or tracheostomytube and type of ventilation• start of compressions• condition of patient before arrest• insertion of any peripheral or central lines• medications administered• fluids administered• lab studies performed • time of defibrillation• other information per facility policy.

Note also whether the patient was repositioned toaccommodate effective resuscitative efforts. The circu-lating nurse must indicate if, for any reason, resuscita-tive efforts were delayed due to wound closure, tableand patient repositioning, or any detachment fromsurgical equipment.

A patient’s condition and disposition at the conclu-sion of the code must be recorded. In the case of suc-cessful CPR, an ICU bed must be requested to facilitate

safe transfer. Notify the family of the delay and docu-ment the notification. Also advise them that the physi-cian will be out to speak with the family as soon as pos-sible. The physician must speak to the family in privateand allow them the opportunity to ask questions.

It’s important that all nursing personnel be familiarwith their institution’s code policy and guidelines. A copy of the code form must be forwarded to thenurse manager and risk management representativefor review, depending on the facility policy. Addition-ally, a post-code debriefing may be conducted to evaluate the performance of the team. The patient’srecord may be reviewed by the risk managementdepartment to ensure elements documented are clearand concise.

Do not resuscitate (DNR) Advance directives were developed to ensure apatient’s ability to participate in the decisions affectingher healthcare. As an amendment to the OmnibusReconciliation Act in 1990, the Patient Self-Determination Act became effective in December1991.8 This act gives the patient the ability to preserveher dignity in end-of-life decisions. It also addresses thefact that Medicare and Medicaid providers arerequired to give an adult patient’s information con-cerning advance directives. These decisions focusedon CPR, intubation, defibrillation and medicationadministration and are components of what’s com-monly referred to as DNR orders.

DNR orders represent the patient’s request fortreatment limitations. Once DNR orders have beenidentified and confirmed with the patient, the chart isflagged to alert the OR team. Preoperatively, patientsshould have a discussion with the surgeon to deter-mine how the DNR will affect them in surgery.9 Theanesthesia provider will specifically review resuscita-tion procedures as they relate to providing anesthesia,and any impact on the postoperative period related tosurgical complications. The surgeon and anesthesiaprovider will discuss all of these areas to ensure agree-ment on the intervention.

The circulator and scrub person need to beinformed of the patient’s DNR status before thepatient is taken to the surgical suite. The circulatormust check the record to confirm that the DNR orderform is signed and the appropriate checks and bal-ances are completed. Automatic suspension of DNRorders undermines the patient’s ability to participate in this process.10


Cardiac arrest

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Both the AORN and American Nurses Associationrecommend that advance directives should be dis-cussed with all adult patients as part of any nursingassessment.10, 11 AORN states that nurses have aresponsibility to uphold the rights of the patient.10

Further-more, as a patient advocate, the perioperativenurse has a moral responsibility to the patient. If anurse is unable to provide for the wishes of thepatient, then that nurse must attempt to find anothernurse willing to provide care to that patient.10 All surgical personnel must be knowledgeable about the DNR procedure. This information should bereviewed during orientation and periodically through-out employment.

The nurse’s roleEarly identification of a potential risk for cardiacarrest, understanding the roles of the personnelinvolved, and providing for the patient’s safety isessential. The knowledge and skills acquired by perioperative nursing staff are used to implementthe nursing process as it relates to a variety of situations. Safe, effective, and efficient care in emer-gency situations depends on the ongoing educationprograms provided. Knowing the expectations ofthe roles involved and equipment used will provideoptimal resuscitative efforts. All staff need to con-sider the “what ifs” to be prepared for adverseevents. OR

REFERENCES

1. American Heart Association. Cardiac Arrest. AHA Recommendation.2007. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4481. Accessed April 2, 2007.

2. Phillips N. Berry & Kohn’s Operating Room Technique. St. Louis, MO.Mosby; 2004.

3. Fink MP, Abraham E, Vincent JL, Kochanek JL. Textbook of CriticalCare. Philadelphia, PA: Elsevier Saunders; 2005.

4. Gabrielli A, Robicsek SA. New Concepts in ACLS. ASA Newsletter.2006;70(4). Available at: http://www.asahq.org/Newsletters/2006/04-06/gabrielli04_06.html. Accessed April 2, 2007.

5. American Society of Anesthesiologists. ASA physical status classifica-tion. Available at: http://www.asahq.org/clinical/physicalstatus.htm. Accessed February 20, 2007.

6. Association of Perioperative Nurses. Standards, recommended practices and guidelines. Denver, CO; 2007.

7. Considine J, Botti M. Who, when and where? Identification of patients of an in-hospital adverse event, implications for nursing practice.A research paper. Int J Nurs Pract. 2004;10:21-31.

8. Patient self-determination act. Ascension Health. Available at:http://www.ascensionhealth.org/ethics/public/issues/patient_self.asp. Accessed February 20, 2007.

9. American College of Surgeons, Statement of the College;[ST-19]Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. Retrieved January 10, 2007. Available at:http://www.facs.org/fellows_info/statements/st-19.html.Accessed April 2, 2007.

10. Association of Perioperative Nurses. Position statement: perioperativecare of patients with do-not-resuscitate (DNR) orders. Denver, CO; 2005.

11. American Nurses Association. Ethics and human rights position state-ment. Available at: http://www.nursingworld.org/readroom/position/ethics/etsdet.htm. Accessed February 20, 2007.

Patricia Woolson is an education consultant, perioperative services, SinaiHospital of Baltimore, Md.

The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

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Responding to Cardiac Arrest

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