Peri‐operative decisions about cardiopulmonary resuscitation among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

Abstract

SummaryCurrent guidance recommends that, in most circumstances, cardiopulmonary resuscitation should be attempted when cardiac arrest occurs during anaesthesia, and when a patient has a pre‐existing ‘do not attempt cardiopulmonary resuscitation’ recommendation, this should be suspended. How this guidance is translated into everyday clinical practice in the UK is currently unknown. Here, as part of the 7th National Audit Project of the Royal College of Anaesthetists, we have: assessed the rates of pre‐operative ‘do not attempt cardiopulmonary resuscitation’ recommendations via an activity survey of all cases undertaken by anaesthetists over four days in each participating site; and analysed our one‐year case registry of peri‐operative cardiac arrests to understand the rates of cardiac arrest in patients who had ‘do not attempt cardiopulmonary resuscitation’ decisions pre‐operatively. In the activity survey, among 20,717 adults (aged > 18 y) undergoing surgery, 595 (3%) had a ‘do not attempt cardiopulmonary resuscitation’ recommendation pre‐operatively, of which less than a third (175, 29%) were suspended. Of the 881 peri‐operative cardiac arrest reports, 54 (6%) patients had a ‘do not attempt cardiopulmonary resuscitation’ recommendation made pre‐operatively and of these 38 (70%) had a clinical frailty scale score ≥ 5. Just under half (25, 46%) of these ‘do not attempt cardiopulmonary resuscitation’ recommendations were formally suspended at the time of anaesthesia and surgery. One in five of these patients with a ‘do not attempt cardiopulmonary resuscitation’ recommendation who had a cardiac arrest survived to leave hospital and of the seven patients with documented modified Rankin Scale scores before and after cardiac arrest, four remained the same and three had worse scores. Very few patients who had a pre‐existing ‘do not attempt cardiopulmonary resuscitation’ recommendation had a peri‐operative cardiac arrest, and when cardiac arrest did occur, return of spontaneous circulation was achieved in 57%, although > 50% of these patients subsequently died before discharge from hospital.

Peri‐operative cardiac arrest in the older frail patient as reported to the 7th National Audit Project of the Royal College of Anaesthetists

“…In half of the cases, DNACPR recommendations were formally suspended during surgery (Table 3). More details on DNACPR and associated outcomes are provided elsewhere [14].…”

Time for new guidelines to focus specifically on cardiac arrest in the peri‐operative period?

“…Calcium may exacerbate injury to an ischaemic myocardium and negatively impact cerebral recovery. As such, it should only be given for hyperkalaemia, calcium channel blocker overdose or hypocalcaemia [3,6]. Sodium bicarbonate was given in 5% of the cases reported to NAP7 and, similarly to calcium, its routine administration is not recommended [3,6].…”

“…Elements of suboptimal peri-operative cardiac arrest care discussed by Nolan et al include the use of adrenaline, calcium and bicarbonate [3]. Recent Resuscitation Council UK guidelines for anaesthetists during peri-operative anaphylaxis discuss the preferential use of small intravenous boluses of adrenaline (e.g.…”

“…This latest guideline essentially permits anaesthetists to use their skills and experience to tailor adrenaline dosing to patient response. Despite the precedent being set in these guidelines, and our experience as anaesthetists at titrating intravenous drugs, the dosing of adrenaline in 65% of the NAP7 peri-operative cardiac arrests followed standard ALS guidelines (1 mg aliquots) [3]. Nine percent of patients reported to NAP7 were given calcium which was associated with a lower rate of return of spontaneous circulation (ROSC) and discharge from hospital (56% vs. 78% and 26% vs. 46%, respectively).…”

“…For context, the average consultant anaesthetist logs 328 anaesthetics per year, so one consultant would experience perioperative cardiac arrest once per decade [2]. Nolan et al have interrogated further detail from the NAP7 dataset and highlighted that, despite evidence that alterations to standard advanced life support (ALS) protocols may be beneficial when a continuously monitored patient is managed directly by an anaesthetist, most patients received standard or non-evidence-based treatments [3].…”