Comments on ‘Cardiac arrest during the perioperative period’

Imagine that in 2023, your team has successfully managed an intraoperative cardiac arrest (IOCA) and you, as head of department, have organised a morbidity and mortality review (MMR). You would like to document whether your team members provided care according to the most recent guidelines on IOCA and, if this were not the case, you would like to improve the practice of your team. As a member of ESAIC you are aware that Guidelines on IOCA have recently been published in the EJA1 but you would also like to update your literature search on IOCA. Current knowledge, embodied by reviews and guidelines on IOCA in adult patients, consists of two review articles published in 2018,2,3 and two guidelines – the European Resuscitation Council Guidelines (ERC) on cardiac arrest in special circumstances, published in 2021,4 and Clinical Practice recommendations also published in 2021.5 A common theme in these publications is the lack of strong evidence underpinning recommendations for clinical practice. One question that you need to address for your projected MMR is whether you limit the analysis of the way the IOCA was managed to the recent ESAIC/ESTES Guidelines or whether you extend your efforts to these other articles cited previously. In this context, the current ESAIC/ESTES Guidelines reinforce the accepted dogma that IOCA represents a subgroup of cardiac arrests, as already identified by the articles previously cited. The current ESAIC/ESTES Guidelines explicitly complement the ERC Guidelines.4 Among the specific features of IOCA, one that is shared by all authors, is the real-time diagnosis of reversible causes of the IOCA. It seems obvious that the present ESAIC/ESTES Guidelines have addressed only a limited number of reversible causes of IOCA, probably because of the lack of evidence. The table in the Supplementary Material enumerates, https://links.lww.com/EJA/A818, without claiming to be exhaustive, the currently accepted reversible causes associated with IOCA. Situations such as dyskalaemia, acute hypersensitivity reactions/anaphylaxis,6 drug intoxication, unrecognised oesophageal intubation,7 cardiac arrest under spinal anaesthesia and others, have not been addressed in the present ESAIC/ESTES Guidelines. Furthermore, in contrast to the two reviews published in 20182,3 that provided explicit clinical reasoning algorithms for different situations, the ESAIC/ESTES Guidelines have not. This is probably explained by a focus on evidence, a major goal of any Guidelines that differentiate them from narrative reviews or expert opinions. The authors of the ESAIC/ESTES Guidelines should be congratulated for the fact that, despite the low level of evidence, they rightly recommend the use of echocardiography (transthoracic or transoesophageal) as an important diagnostic tool to rapidly identify possible (potentially reversible) causes of IOCA. By taking into consideration the availability and skills to perform echocardiography during resuscitation of an IOCA, they accept that this is not yet available in all hospitals/situations. Point of care ultrasound (POCUS) examination is also an important diagnostic tool (tension pneumothorax for example). There is little doubt that these diagnostic approaches can improve and accelerate the diagnostic process to identify the causes/mechanisms of IOCA.8–11 In terms of therapeutic interventions, the authors of the ESAIC/ESTES Guidelines consider the timely use of extracorporeal life support (ECLS) as an important therapeutic tool for many causes of IOCA. The authors also propose a few other ‘heroic’ measures such as open chest cardiac massage, resuscitative thoracotomy for descending aorta cross-clamping or resuscitative endovascular balloon occlusion of the aorta (REBOA), the last two being ‘heroic’ interventions in cases of haemorrhage-related IOCA despite a jarring lack of evidence. The authors also note a lack of effectiveness of these interventions among patients with traumatic cardiac arrest, and possible harm. Therefore, these interventions should only be considered experimental, without any recommendations. The applicability and feasibility of these heroic approaches is also questionable when ECLS is not available, for example in general hospitals without cardiothoracic surgery services. Finally, once these ESAIC/ESTES Guidelines are adopted, how should institutions/departments of anaesthesia/single anaesthesiologists adopt and implement them? What we suggest is the following: (1) Complement knowledge on IOCA with the articles cited previously and emphasise timely diagnosis and treatment of reversible causes (see examples in the table in the Supplementary Material, https://links.lww.com/EJA/A818). (2) Adopt without restrictions the recommendations regarding the cardiac arrest team and simulation training for IOCA because they are credible measures to improve quality of care and patient safety, especially with a (relatively) infrequent event such as IOCA. (3) Adopt the recommendation on the timely use of echocardiography and POCUS and complement the ESAIC Guidelines with a few recent articles.8–11 (4) Consider the availability and training for transthoracic or transoesophageal emergency temporary pacing in cases of asystole (with a P wave present in the ECG), as recommended by the ESAIC/ESTES Guidelines. (5) Define, at the level of the institution/department of anaesthesia, a strategy for refractory cardiac arrest situations and the timely use of ‘heroic’ interventions such as ECLS, resuscitative thoracotomy, REBOA etc. In conclusion, the MMR should focus on how your team was able to work quickly to manage IOCA because they had been trained using simulators for this rare but devastating event. It should highlight how your department's members were proficient in the use of echocardiography and POCUS to diagnose possible causes of IOCA. It should address how reversible causes were quickly identified and dealt with. Finally, it should demonstrate how the team handled risk–benefit considerations of advanced modalities such as ECLS, resuscitative thoracotomies and REBOA.