Special Articles

Peri-operative Cardiac Arrest: Teamwork And Management

Abhijit Nair1, Vibhavari Naik1, Basanth Kumar Rayani2

1Consultant Anesthesiologist; 2Chief Anaesthesiologist

Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana 500034, (India)

Correspondence: Dr Abhijit Nair, Department of Anesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Road No 10, Banjara Hills, Hyderabad, Telangana 500034, (India); Phone: 040-23551235; E-mail: abhijitnair95@gmail.com

ABSTRACT

Perioperative cardiac arrest is an unfortunate event that can have disastrous outcomes if not attended and intervened on time. Arrests occurring intraoperatively have usually good outcomes as the patient is continuously monitored and it is easy to find out the cause of cardiac arrest. Patients coming for emergency surgeries, advanced ASA physical status, extremes of age groups (geriatric, pediatric) are the candidates in which perioperative cardiac arrest occurs. Events precipitating cardiac arrests should be identified early in wards. However once an arrest occurs in wards, the overall outcome depends on the timing, efforts of the resuscitation team and the events leading to cardiac arrest.

Key words: Perioperative; Cardiac arrest; Anesthesia; Mortality; Intraoperative

Citation: Nair A, Naik V, Rayani BK. Perioperative cardiac arrest: teamwork and management. Anaesth Pain & Intensive Care. 2016;20 Suppl 1:S97-S105

Received: 20 August 2016; Reviewed: 12 September 2016; Accepted: 23 September 2016

INTRODUCTION

Managing unexpected perioperative events can be challenging for the attending

anesthesiologist. Although few events might be anticipated in sick patients, a thorough preoperative evaluation for an elective surgery doesn’t always guarantee that nothing will go wrong. Unexpected events can compromise patient safety or turn out to be life threatening if appropriate equipment, protocols and help are not readily available.

To analyze this, a symposium issue was published by Anesthesia and Intensive Care in 1993 after the Australian Incident Monitoring Study (AIMS) that was started in 1988. The paper reviewed 2000 incidents presented in 30 papers that addressed different types of anesthetic incidents like anaphylaxis, difficult intubation, cardiac arrest, wrong drug administration.1

There is no uniform definition for perioperative cardiac arrest (POCA) in literature. As the terminology implies, POCA is a cardiac arrest occurring during induction of anesthesia, intra-operatively or post-operatively.2 Any POCA happening after 24 hours of surgery can be of anesthetic or non-anesthetic etiology. Cardiac arrest due to accidental or wrong drug administration or inadvertent intravenous local anesthetic injection can also be considered under anesthetic etiology. Any event which requires chest compressions perioperatively should be considered as a POCA.

Cardiac arrest occurring in the perioperative period is a potentially reversible event. In hospital cardiac arrest has better outcomes compared to the cardiac arrests occurring in the community that are not witnessed. This is due to the availability of monitoring, equipment for resuscitation and trained personnel in the hospital. The incidence of POCA is varied in different parts of the world, ranging from 3-163 per 10,000 surgeries. This difference could be due to different patient types, available facilities, infrastructure and efficiency of support system, which gets reflected in the morbidity/mortality/ adverse event statistics. Although the incidence of anesthesia related cardiac arrest is reducing all over the world due to modern equipment, mandatory training in resuscitation and simulator based learning, the overall incidence of POCA remains more or less the same. This could be due to patients with advanced ASA physical status, emergency surgeries and more complex procedures due to advances in the field of medicine. In a prospective study done by Sebbaq et al3 involving 40,379 anesthetics between January to December 2007, 52 patients had cardiac arrest intraoperatively. Though 69% patients had return of spontaneous circulation after the initial arrest, 30 day survival was seen in only 25% of patients.

The factors responsible for such a short survival rate were found to be: ASA physical status IV and V, emergency surgery, hemorrhagic events, hypovolemia and use of atropine during resuscitation. Dedicated team work can have favorable results when it is applied to perioperative care of surgical patients, especially the sick ones (emergency surgeries, elderly patients, patients with advanced ASA physical status, neonates and infants). The team should involve the operating surgeon, anesthesiologists and the specialists who were involved in patient’s care perioperatively (e.g. cardiologist, nephrologist, pulmonologist, obstetrician, oncologist etc.). The team should meet to discuss the patient’s progress and to decide the management plan till the patient gets discharged from the hospital. Anesthesiologist forms an important link for coordinating the team.

LITERTURE REVIEW

In the studies involving interpretation of prospective or retrospective data related to perioperative cardiac arrest, the incidence was particularly higher in emergency surgeries compared to elective surgeries.4 This is seen because the emergency surgical patient comes to operation theatre without detailed preoperative workup and thus is not optimized compared to the elective counterpart . The other area which was striking after reviewing literature was the extremes of age (geriatric patients and neonates).5,6 Even though elective surgical patients are thoroughly worked up, factors like prolonged surgery, advanced ASA physical status, perioperative blood transfusions, acute kidney injury, electrolyte imbalances, ventilatory support, nosocomial infections etc. are not always predictable. All the above mentioned factors either alone or in combination could be held responsible for triggering or predisposing to cardiac arrest.

All the data of perioperative and intraoperative deaths published in indexed journals have been collated. To collect this information we searched Pubmed, Medline, Scopus, Embase with following keywords: perioperative, cardiac arrest, anesthesia, mortality and intraoperative.

In all we have presented a summary of 12 papers published in reputed journals in a tabular form (Table 1). We have mentioned the type of study (retrospective, prospective, observational), the type of event described in the paper i.e. perioperative, intraoperative or both, the time frame in which the analysed data was collected and the incidence of mortality derived in that particular paper.

Table 1: A summary of 12 papers published7-18

No. Authors Type of study Type of event Duration of data Incidence
1. Siriphuwanun et al Retrospective cohort Within 24 hrs of anaesthesia 8 yrs (from 2003-2011): 44,339 patients 163/10,000
2. Tamdee et al Retrospective Perioperative Between 2003-2007. Incidence of 24-hour perioperative cardiac arrest : 40.4/10,000
3. Siracuse et al Retrospective (National Surgical Quality Improvement Program data ) Perioperative

( Vascular surgery )

 3 yrs

( 2007-2010 )

 1% patients

( out of 123,581 patients, 1234 patients had cardiac arrest )
4. Nunes et al Retrospective data ( from teaching hospital ) Perioperative 15 yrs

( 1996-2010)

 54.44/10,000 anesthetics
5. Kazaure et al Retrospective cohort study(American College of Surgeons–National Surgical Quality Improvement Program) Perioperative 6 yrs

(2005-2010)

 1 in 203 surgical cases
6. Braz et al Retrospective data Perioperative 9 yrs

(1996-2005)

 34.6/10,000
7. Goswami et al Prospective

(American College of Surgeons

National Surgical Quality Improvement Program database)

 Intraoperative 3 yrs

(2005-2007)

 7.22/10,000
8. Messahel et al Retrospective Perioperative 18 yrs

(1992-2010)

 0.03%

( 3/10,000)

 
9. Vane et al Retrospective ( a review of data from tertiary and academic hospitals) Intraoperative Included studies conducted between 1982-2007. Incidence changed from 39/10,000 to 13/10,000 in the duration of 25 yrs
10. Nunnally et al

 

 

 Retrospective

(National Anaesthesia Clinical Outcomes Registry)

 

 Perioperative

 

 

 

 

 4 yrs ( 2010-2013)

 

 

 

 5.6/10,000

 

 

 
11. Gonsalez et al Observational Intraoperative and perioperative (pediatric patients ) 2005-2010 Incidence of cardiac arrest 20.65/10,000, incidence of death 10.32/10,000
12. Bharti et al Retrospective Perioperative 2003-2008 Anaesthesia

related

mortality :1.2/10 000 ,

7.7/10 000 anaesthetics with a survival rate of 56%.

 

Runciman et al19 reviewed 4000 incidents reported to Australian Incident Monitoring Study and identified 24 specific anaesthesia crisis situations. With the help of teams of practising anaesthesiologists, they developed management algorithms. The authors had first published the algorithm in 1993 and in 2005 they reemphasized the importance of using these algorithms. The algorithms provide a clear insight on how to approach a crisis during anaesthesia management. Having such algorithms in operation room (OR) /ICU as a ready reference can be useful (Table 2). The algorithm is named as “COVER ABCD – A SWIFT CHECK”. COVER includes circulation, oxygen, ventilation / vaporises, endotracheal tube and review. ABCD is airway, breathing, circulation, drugs as in ACLS. “A SWIFT CHECK” pneumonic is for differential diagnosis to short list the cause of event, similar to 5H’s and 5T’s in ACLS course.

Table 2: Crisis management algorithm: ‘COVER ABCD’

C1 Circulation Establish adequacy of peripheral circulation (rate, rhythm and character of pulse). If pulseless, institute cardiopulmonary resuscitation (CPR). The core algorithm must still be completed as soon as possible.
C2 Colour Note saturation. Examine for evidence of central cyanosis. Pulse oximetry is superior to clinical detection and is recommended. Test probe on own finger, if necessary, whilst proceeding with O1 and O2.
O1 Oxygen Check rotameter settings, ensure inspired mixture is not hypoxic.
O2 Oxygen analyser Adjust inspired oxygen concentration to 100% and note that only the oxygen flowmeter is operating. Check that the oxygen analyser shows a rising oxygen concentration distal to the common gas outlet.
V1 Ventilation Ventilate the lungs by hand to assess breathing circuit integrity, airway patency, chest compliance and air entry by ‘‘feel’’ and careful observation and auscultation. Also inspect capnography trace.

 
V2 Vaporiser Note settings and levels of agents. Check all vaporiser filler ports, seatings and connections for liquid or gas leaks during pressurisation of the system. Consider the possibility of the wrong agent being in the vaporiser.
E1 Endotracheal tube Systematically check the endotracheal tube (if in use). Ensure that it is patent with no leaks or kinks or obstructions. Check capnograph for tracheal placement and oximeter for possible endobronchial position. If necessary, adjust, deflate cuff, pass a catheter, or remove and replace.
E2 Elimination Eliminate the anaesthetic machine and ventilate with self-inflating (e.g. Air Viva) bag with 100% oxygen (from alternative source if necessary). Retain gas monitor sampling port (but be aware of possible problems).
R1 Review monitors Review all monitors in use (preferably oxygen analyser, capnograph, oximeter, blood pressure, electrocardiograph (ECG), temperature and neuromuscular junction monitor). For proper use, the algorithm requires all monitors to have been correctly sited, checked and calibrated.
R2 Review equipment Review all other equipment in contact with or relevant to the patient (e.g. diathermy, humidifiers, heating blankets, endoscopes, probes, prostheses, retractors and other appliances).
A Airway Check patency of the non-intubated airway. Consider laryngospasm or presence of foreign body, blood, gastric contents, nasopharyngeal or bronchial secretions.
B Breathing Assess pattern, adequacy and distribution of ventilation. Consider, examine and auscultate for bronchospasm, pulmonary oedema, lobar collapse and pneumo- or hemothorax.
C Circulation Repeat evaluation of peripheral perfusion, pulse, blood pressure, ECG and filling pressures (where possible) and any possible obstruction to venous return, raised intrathoracic pressure (e.g. inadvertent PEEP) or direct interference to (e.g. stimulation by central line) or tamponade of the heart. Note any trends on records.

 

 
D Drugs Review intended (and consider possible unintended) drug or substance administration.

Consider whether the problem may be due to unexpected effect, a failure of administration or wrong dose, route or manner of administration of an intended or ‘‘wrong drug’’. Review all possible routes of drug administration.

(Table reproduced with permission from the publisher, BMJ Publishing Group Ltd.; license number: 3874521013406)

Table 3: ‘A SWIFT CHECK’ checklist

  Condition Comments
A Air embolus Hypotension, hypocarbia
A Anaphylaxis Hypotension, bronchospasm, urticaria
A Air in pleura Pneumothorax, circulatory/ respiratory deterioration
A Awareness Dilution of anesthetic agents
S Surgeon/situation Vagal stimulus, cord compression, bleeding, myocardial stimulation
S Sepsis Hypotension, desaturation, acidosis, hyperdynamic circulation
W Wound Trauma, bleeding, tamponade, pneumothorax, retractors
W Water intoxication Electrolyte imbalance, fluid overload
I Infarct Myocardial conduction/ rhythm problem, hypotension, poor cardiac output
I Insufflation Vagal tone, gas embolism, reduced venous return
F Fat syndrome Desaturation, hypotension
F Full bladder Sympathetic stimulation
T Trauma Spinal injury, diaphragmatic injury, ruptured viscus
T Tourniquet down LAST, bleeding
C Catheter/IV cannula/chest drain Leaks, obstruction, wrong connection, wrong rate
C Cement Hemodynamic changes with methyl acrylate
H Hyper/hypothermia Tachy/bradycardia, ECG changes
H Hypoglycemia Fasting, beta blockers, preop inadvertent insulin
E Embolus Fat, amniotic fluidà hypotension, hypocarbia, ECG changes
E Endocrine Thyroid, adrenal, pituitary, pancreas
C Check Right patient, right operation, right surgeon
C Check Case notes, preop status, drugs, diseases

 
K K+ Potassium and other electrolyte : ECG changes, CNS signs
K Keep Keep the patient asleep until a new anesthetic machine can be obtained

 


INTRA-OPERATIVE CARDIAC ARRESTS:20

Intraoperative cardiac arrests i.e. the cardiac arrests occurring during induction of anaesthesia, intraoperatively and immediate post-operatively (after extubation or after shifting to ICU) are always noticed events because the patient is continuously monitored and have good outcomes if addressed on time. Following are the most frequent causes of intraoperative cardiac arrest (Table 3).

  1. ASA Physical Status

Patients with advanced ASA have several systemic co-morbidities which can decompensate during induction of anaesthesia or perioperatively. Elderly patients and pediatric patients with underlying medical problems are the group of patients that are susceptible for POCA.

  1. Emergency Surgery:

The incidence of POCA is more than twice for a patient who has an emergency surgical intervention. These are the patients who are unoptimized. A thorough medical workup and assessment is not possible especially if the surgery is lifesaving. In such situations, hemodynamic events and respiratory issues encountered are more. Emergency surgical intervention is usually carried out in odd hours when the medical and surgical staff are less and an urgent help is not available in case of a life threatening event.

  • Ventilation Related:

Having a CVCI (cannot ventilate, cannot intubate) situation is a nightmare for the anaesthesiologist. However if one encounters a CVCI, an alternative plan for ventilation and oxygenation should be available in the OR premises (supraglottic airways, jet ventilator, cricothyrotomy kit). A team work involving a second anesthesiologist, technician and surgeon – knowing their role in the airway plan is important. If hypoxia is unaddressed by alternative means, cardiac arrest is inevitable especially in neonates/ infants and sick patients.

  1. Local Anaesthesia Systemic Toxicity (LAST):

LAST is potentially life threatening event which can have disastrous outcomes. With the use of ultrasound for peripheral nerve blocks, regional anaesthesia has become safe but in spite of that case reports and series are published from centres were ultrasound is used in high volumes and has been used for years . Applying principles of ACLS and having lipid infusion in hand can prevent mortality. Bretylium is not available everywhere and a provision for emergency cardiopulmonary bypass is not possible in all hospitals (especially in non- cardiac centres). A high degree of clinical suspicion and applying principles of ACLS is important when one encounters LAST. Team work is important in such situations.

  1. Excessive Parasympathetic Tone:

Bradycardia/ asystole happening due to excessive parasympathetic tone is usually transient if addressed and rectified. In neonates/infants/pediatric patients, it can be treated with a dose of anticholinergic drug (atropine, glycopyrrolate). In adults, the bradycardic response is seen during port insertion for laparoscopic surgeries, peritoneal stretching during abdominal surgeries and at times as a laryngoscopic response.

  1. Medication-related:

Induction agents like propofol when given in usual doses to sick patients can lead to worsening of LV function, excessive vasodilatation, refractory hypotension eventually leading to cardiac arrests. This can be avoided by selecting the induction agent carefully for every patient. Etomidate, inhalational induction or induction using a benzodiazepine with narcotic combination can be useful in such situations. In sick and hypovolemic patients, even spinal/ epidural anaesthesia can lead to major adverse cardiac event due to vasodilatation leading to shock. If such situations are not addressed on time, the end result is a cardiac arrest. Excessive doses of narcotic, extubation in a deep anaesthetic plane can also lead to airway obstruction leading to cardiac arrest if not monitored and planned properly. The consequences of wrong drug administration can be catastrophic and life threatening.

  • Sepsis/ SIRS:

Presence of septic focus and having SIRS or impending sepsis are usually patients coming for emergency or urgent surgeries. During surgery when handling the focus of infection, bacterial endotoxinemia and release of inflammatory mediators (IL-6, cytokines) can present with serious hemodynamic events which can precipitate cardiac arrest intraoperatively or post operatively. Careful induction, having invasive lines and proper empirical antibiotic administration if cultures are not available should be the strategy in such patients.

  • Miscellaneous:

Prolonged surgery (more than 4-6 hours), massive blood transfusion, surgery in odd hours like emergency surgeries where urgent help is not available and prolonged intraoperative hypotension are other important factors that are responsible for POCA. These factors should be considered as possibilities either alone or in combination when one is investigating a POCA.

Table 4: Most frequent causes of POCA and the common location of its occurrence

Etiology Location
ASA physical status OR/ ICU/wards
Emergency surgery OR/ICU
Ventilation (CVCI / postextubation laryngospasm) OR/ICU
LAST (local anaesthesia systemic toxicity) OR/ICU/ wards
Excessive sympathetic tone OR
Medication errors OR/ICU/ wards
Sepsis / SIRS OR/ICU/ wards
Miscellaneous (duration, intra-operative hypotension, blood transfusion) OR/ICU/ wards

 

Following are the general resuscitation principles which should be strictly adhered to, whenever a cardiac arrest occurs in the operation theatre premises.19

  1. Apply the algorithm of COVER ABCD – A SWIFT CHECK
  2. Inform the surgeon and stop the ongoing surgery
  3. If prone or lateral decubitus, turn the patient supine
  4. Apply principles of Basic/ advanced life support if cardiac arrest is confirmed
  5. Analyse the rhythm
  6. Consider intubation and ventilation with 100% oxygen if not already intubated
  7. Discuss differential diagnosis and plan manage accordingly

 

CARDIAC ARRESTS IN WARD

After getting shifted, on the ward the patients are monitored on an hourly or an intermittent basis. Very rarely, continuous monitoring occurs. If the early warning signs are ignored, the results can be catastrophic. Surgical problems like bleeding can be addressed by exploration, if the patient is resuscitated well and shifted to the OR on time. However, medical problems can have equivocal outcomes. Complications like pulmonary embolism, major adverse cardiac events, arrhythmias, stroke can have poor outcomes unless addressed early. Although considerable improvement has been in the last decade, neurological deficits were common in patients who survived resuscitation after cardiac arrest occurring on the ward.21 The reason for ROSC could be improvement in standards of resuscitation because of compulsory training of all personnel involved in acute care (physicians, anesthesiologists, intensivists, surgeons, nursing staff working in critical areas or high dependency areas and paramedics).

If the rhythm on the monitor is a shockable (VT/VF), early defibrillation can lead to a successful ROSC (return of spontaneous circulation). However if ROSC occurs after more than 30 min of resuscitation, the outcome is usually poor due to hypoxic brain damage.

CODE BLUE TEAM

Code blue is a communication system used to indicate and alert the healthcare professionals, about a patient at a particular location in the hospital who needs resuscitation. The code is activated by an internal telephone system, pagers and loudspeaker announcement in the hospital.22 A properly established code blue system reflects the organisational efficacy of the hospital. An audit of the code blue events can provide information about the areas of resuscitation which needs improvement. Frequent simulation based training and mock drills can help in practising the skills and algorithms of resuscitation.23

The reason for activating a code could be a respiratory arrest, cardiac arrest or a peri-arrest situation. The team members are expected to reach the location with all resuscitation equipment including a defibrillator and apply the principles of advanced cardiopulmonary life support. The team usually involves an anaesthesiologist, emergency physician, surgeon, cardiologist, trained nursing staff, respiratory therapist or a technician (ICU, anaesthesia). On arrival the team should be able to perform high quality chest compressions, ventilation either with bag/mask or definitive airway, drug administration, defibrillation etc. Rhythm analysis is a very important part of CPR after good quality chest compression. Identifying a shockable rhythm and defibrillating with the correct energy (in Joules) can lead to a successful resuscitation. Post resuscitation care in an appropriate critical care area is equally important.

 

TEAMWORK IN A PERIOPERATIVE PATIENT

Team dynamics:

A team is a group of individuals working towards a common goal. A well-orchestrated team effort would not have a better application than in a perioperative cardiac arrest, which is a potentially reversible one. ACLS course describes the importance of the role of team dynamics in carrying out a successful resuscitation. Similarly, in an OR complex any cardiac arrest should be managed by following effective resuscitation team dynamics. As OR is a restricted area, all code blue team members might not be able to enter the complex. A code blue is not always activated when an event occurs in the OR as an anaesthesiologist is always available and the patient is being monitored.

The following are the elements of effective resuscitation team dynamics described in the ACLS course24

  1. Closed- loop communications
  2. Clear messages
  3. Clear role and responsibilities
  4. Knowing one’s limitations
  5. Knowledge sharing
  6. Constructive intervention
  7. Re-evaluation and summarizing
  8. Mutual respect

The team dynamics can be continuously improved by conducting simulation training or mock drills in the operating room setting. Simulators help to imitate or rehearse perioperative life threatening events. Appropriate communication with other members of the team, decision making and implementation can be practised and replicated in an interactive manner. Simulation can be interrupted for teaching or discussion so that the skills are reinforced.25,26

The non-medical team members should also be trained in basic life support so that they can also be the part of resuscitation during a critical incident. During mock drills and simulator sessions, the role of a team member should be specifically assigned so that every member knows what is expected of them in real time during an incident.27

Lerner et al28 had proposed that a healthcare system that supports effective teamwork can improve the quality of patient care and reduce workload issues that cause burnout among healthcare professionals. However, this teamwork concept can be successful only if all team members follow the code of conduct of team dynamics. Regular audit should be performed for evaluating the practices and suggesting improvement.

Anaesthesiologist as a perioperative physician:29,30

Anaesthesiology is a multifaceted discipline. An anaesthesiologist should have knowledge of basic medical sciences, pathophysiology relevant to all diseases, implications of surgical intervention on homeostasis along with the syllabus of anaesthesiology. During pre-anaesthesia check-up, the anaesthesiologist does a thorough general, physical and systemic examination. The patient is advised further evaluation by specialists when indicated. Intraoperatively the anaesthesiologist monitors and maintains the normal physiology of the patient and addresses the critical care issues in postoperative period Anaesthesiologist is also involved in preventing perioperative surgical site infections, managing respiratory and perioperative nutrition related issues. In a recently published review by Wacker et al, the authors have summarised the preventable causes of perioperative adverse events. They have mentioned that an anaesthesiologist is a dynamic perioperative physician and are considered as pioneers in patient safety. They should be take lead in perioperative care of patients especially the sick ones so that potentially avoidable events can be prevented.

Follow-up on the wards:

A sick patient requiring emergency surgery, a patient with multiple co-morbidities, a patient who had a stormy post-operative course (massive blood loss, MACE, airway emergency, anaphylaxis etc) are the patients who might have a cardiac arrest post-operatively. Due to this reason, the team of doctors involved in the care (anaesthesiologists, surgeons, intensivist, pulmonologist, nephrologist and cardiologist) usually have to follow up at least once daily depending upon the type of co-morbidity. The nursing staff should be trained to use MEWS (Modified Early Warning System) to identify a predisposing factor which could lead to a cardio-respiratory event. A score of 5 or more than 5 has been shown to be responsible for higher possibility of a life threatening event leading to ICU admission.31

If a postoperative patient ends up in a cardiac arrest on the ward, it is usually the anaesthesiologist who is the team leader conducting the resuscitation and managing the patient if further surgical intervention is required. It would be ideal if the anaesthesiologist could visit the sick patients who are transferred from the ICU to the ward at least once a day. During such visits, early signs of deterioration may be picked up and addressed appropriately.\

CONCLUSION

In spite of advances in healthcare, compulsory training for doctors and paramedical staff in basic and advanced life support, the incidence of POCA continues to remain the same. However, the rate of survival after POCA, has improved significantly over the years. POCA is an unpredictable entity but patients with predisposing factors should be monitored closely and appropriate interventions should be performed early all through the perioperative period – from admission to discharge. POCA leading to significant morbidity can be avoided by following protocols and checklists. Effective team dynamics, following life support protocols, thorough evaluation of the patient should be done and all team members should be aware of the events. Events should be documented in the case notes and discharge summary.

Conflicts of interest: NIL

Acknowledgement: NIL

Authors’ contribution: All authors participated in concept, design, literature search, manuscript preparation & review

REFERENCES

  1. Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):520-8.[PubMed] [Free full text]
  1. Sprung J ,Flick RP, Gleich SJ, Weingarten TN. Perioperative Cardiac Arrests. Signa Vitae 2008;3(2): 8-12.
  1. Sebbag I, Carmona MJ, Gonzalez MM, Alcântara HM, Lelis RG, Toledo Fde O et al. Frequency of intraoperative cardiac arrest and medium-term survival. Sao Paulo Med J. 2013;131(5):309-14. [PubMed] [Free full text] doi: 10.1590/1516-3180.2013.1315507.
  1. Siriphuwanun V, Punjasawadwong Y, Lapisatepun W, Charuluxananan S, Uerpairojkit K. Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anaesthesia for emergency surgery. Risk Manag Healthc Policy. 2014;7:155-62.
  1. Tamdee D, Charuluxananan S, Punjasawadwong Y, Tawichasri C, Kyokong O, Patumanond J et al. Factors related to 24-hour perioperative cardiac arrest in geriatric patients in a Thai university hospital. J Med Assoc Thai. 2009;92(2):198-207. [PubMed]
  1. Gobbo Braz L, Braz JR, Módolo NS, do Nascimento P, Brushi BA, Raquel de Carvalho L. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth. 2006;16(8):860-6. [PubMed] [Free full text] doi: 10.1111/j.1460-9592.2006.01876.x
  1. Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075-81. [PubMed] [Free full text] doi: 10.1016/S0140-6736(12)60990-8
  1. Carlucci MTO, Braz JRC, do Nascimento P, de Carvalho LR, Castiglia YMM, Braz LG. Intraoperative Cardiac Arrest and Mortality in Trauma Patients. A 14-Yr Survey from a Brazilian Tertiary Teaching Hospital. Ang D, ed. PLoS One. 2014;9(2):e90125.[PubMed] [Free full text] doi: 10.1371/journal.pone.0090125
  1. Kazaure HS, Roman SA, Rosenthal RA, Sosa JA. Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP. JAMA Surg. 2013;148(1):14-21. [PubMed] [Free full text] doi: 10.1001/jamasurg.2013.671.
  1. Koga FA1, El Dib R, Wakasugui W, Roça CT, Corrente JE, Braz MG, et al. Anaesthesia-Related and Perioperative Cardiac Arrest in Low- and High-Income Countries: A Systematic Review With Meta-Regression and Proportional Meta-Analysis. Medicine (Baltimore). 2015;94(36):e1465.[PubMed] [Free full text] doi: 10.1097/MD.0000000000001465.
  1. Nunnally ME , O’Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anaesthesia clinical outcomes registry. Anesth Analg. 2015;120(2):364-70. [PubMed] [Free full text] doi: 10.1213/ANE.0000000000000527.
  1. JJ , Meltzer EC , Gill HL , Graham AR , Schneider DB , Connolly PH et al. Outcomes and risk factors of cardiac arrest after vascular surgery procedures. J Vasc Surg. 2015;61(1):197-202. [PubMed] [Free full text] doi: 10.1016/j.jvs.2014.06.118.
  1. Nunes JC, Braz JRC, Oliveira TS, de Carvalho LR, Castiglia YMM, Braz LG. Intraoperative and Anaesthesia-Related Cardiac Arrest and Its Mortality in Older Patients: A 15-Year Survey in a Tertiary Teaching Hospital. PLoS One. 2014;9(8):e104041. [PubMed] [Free full text] doi: 10.1371/journal.pone.0104041.
  1. Braz LG, Módolo NSP, do Nascimento Jr, Bruschi BAM, Castiglia YMM, Ganem EM et al. Perioperative cardiac arrest: a study of 53 718 anaesthetics over 9 yr from a Brazilian teaching hospital. Br J Anaesth.2006;96(5):569-75.[PubMed] [Free full text] doi: 10.1093/bja/ael065.
  1. Goswami S, Brady JE, Jordan DA, Li G. Intraoperative cardiac arrests in adults undergoing noncardiac surgery: incidence, risk factors, and survival outcome. Anesthesiology. 2012 ;117(5):1018-26. [PubMed] [Free full text] doi: 10.1097/ALN.0b013e31827005e9.
  1. Runciman WB, Kluger MT, Morris RW, Paix AD, Watterson LM, Webb R. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. 2005;14(3):e1. [PubMed] [Free full text] doi: 10.1136/qshc.2002.004101.
  1. Gonzalez LP, Braz JR, Módolo MP, de Carvalho LR, Módolo NS, Braz LG. Pediatric perioperative cardiac arrest and mortality: a study from a tertiary teaching hospital. Pediatr Crit Care Med. 2014;15(9):878-84. [PubMed]

doi: 10.1097/PCC.0000000000000248.

  1. Bharti N, Batra YK, Kaur H. Paediatric perioperative cardiac arrest and its mortality: database of a 60-month period from a tertiary care paediatric centre. Eur J Anaesthesiol. 2009 ;26(6):490-5. [PubMed]

doi: 10.1097/EJA.0b013e328323dac0.

  1. Runciman WB, Morris RW, Watterson LM, Williamson JA, Paix AD. Crisis management during anaesthesia: cardiac arrest. Qual Saf Health Care. 2005;14(3):e14.[PubMed] [Free full text] doi: 10.1136/qshc.2002.004473.
  1. Ellis SJ, Newland MC, Simonson JA, Peters KR, Romberger DJ, Mercer DW et al. Anaesthesia-related cardiac arrest. Anesthesiology. 2014 Apr;120(4):829-38. [PubMed] [Free full text] doi: 10.1097/ALN.0000000000000153.
  1. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in Survival After In-Hospital Cardiac Arrest. The New England journal of medicine. 2012;367(20):1912-20. [PubMed] [Free full text] doi: 10.1056/NEJMoa1109148.

http://www.nejm.org/doi/full/10.1056/NEJMoa1109148

  1. Bayramoglu A, Cakir ZG, Akoz A, Ozogul B, Aslan S, Saritemur M. Patient-Staff Safety Applications: The Evaluation of Blue Code Reports. The Eurasian J Med. 2013;45(3):163-6.[PubMed] [Free full text] doi: 10.5152/eajm.2013.34.
  1. Huseman KF. Improving code blue response through the use of simulation. J Nurses Staff Dev. 2012;28(3):120-4. [PubMed] doi: 10.1097/NND.0b013e3182551506.
  1. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S414-35. [PubMed] [Free full text] doi: 10.1161/CIR.0000000000000259.
  1. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-51. [PubMed] [Free full text] doi: 10.1111/j.1399-6576.2008.01717.x.
  1. Manser T, Harrison TK, Gaba DM, Howard SK. Coordination patterns related to high clinical performance in a simulated anesthetic crisis. Anesth Analg. 2009;108(5):1606-15. [PubMed] doi: 10.1213/ane.0b013e3181981d36.
  1. Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework for the intensive care unit. Crit Care Med.2009;37(5):1787-93. [PubMed] doi: 10.1097/CCM.0b013e31819f0451.
  1. Lerner S, Magrane D, Friedman E. Teaching teamwork in medical education. Mt Sinai J Med. 2009;76(4):318-29. [PubMed] [Free full text] doi: 10.1002/msj.20129
  1. Wacker J, Staender S. The role of the anaesthesiologist in perioperative patient safety. Curr Opin Anaesthesiol. 2014;27(6):649-56. [PubMed] [Free full text] doi: 10.1097/ACO.0b013e3282f70042.
  1. Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: Are their roles complementary? Proc (Bayl Univ Med Cent). 2007;20(2):140-2. [PubMed] [Free full text]
  1. Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The Value of Modified Early Warning Score (MEWS) in Surgical In-Patients: A Prospective Observational Study. Ann R Coll Surg Engl. 2006;88(6):571-5. [PubMed] [Free full text] doi: 10.1308/003588406X130615