What Advanced Cardiovascular Life Support (ACLS) protocols are recommended for anesthetized patients?

ACLS Protocols for Anesthesia Patients

Standard ACLS protocols should be followed for anesthetized patients with modifications specific to the anesthesia setting, focusing on high-quality CPR, early defibrillation, and addressing anesthesia-specific causes of arrest. 1

Core ACLS Components for Anesthetized Patients

Immediate Actions

• Recognize cardiac arrest (absence of pulse, blood pressure, end-tidal CO2)
• Call for help and activate code team
• Begin high-quality CPR:
  • Push hard (at least 2 inches/5 cm) and fast (100-120/min)
  • Allow complete chest recoil
  • Minimize interruptions in compressions
  • Change compressor every 2 minutes or sooner if fatigued 1

Airway Management

• Verify endotracheal tube placement using waveform capnography
• If not already intubated, consider either:
  • Endotracheal intubation by qualified provider
  • Supraglottic airway device
• Once advanced airway is in place, deliver 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 1

Rhythm Assessment and Defibrillation

• Quickly identify cardiac rhythm
• For VF/pVT:
  • Immediate defibrillation
  • Resume CPR immediately after shock
  • Consider either amiodarone or lidocaine for shock-refractory VF/pVT
    • Amiodarone: First dose 300 mg bolus, second dose 150 mg
    • Lidocaine: First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg 1

Anesthesia-Specific Considerations

Anesthesia-Related Causes of Arrest

• Immediately consider and address:
  • Hypoxemia (disconnect from ventilator, difficult airway)
  • Hypovolemia (surgical bleeding, fluid shifts)
  • Anaphylaxis to anesthetic agents
  • Local anesthetic toxicity
  • Malignant hyperthermia
  • Tension pneumothorax
  • Vagal responses
  • Medication errors or interactions

Monitoring During Resuscitation

• Utilize available anesthesia monitors:
  • Continuous waveform capnography (PETCO2)
    • PETCO2 <10 mm Hg indicates need to improve CPR quality
    • Abrupt sustained increase (typically >40 mm Hg) suggests ROSC 1
  • Arterial line monitoring if available
    • Diastolic pressure <20 mm Hg indicates need to improve CPR quality
    • Spontaneous arterial pressure waves indicate ROSC 1
  • Consider cardiac ultrasound if available without interrupting CPR 1, 2

Drug Administration

• Utilize existing IV/IO access from anesthesia
• Epinephrine 1 mg IV/IO every 3-5 minutes 1
• Consider vasopressin as alternative or in addition to epinephrine
• For local anesthetic toxicity:
  • Administer IV lipid emulsion therapy per protocol

Post-ROSC Care

• Maintain Paco2 within normal physiological range
• Avoid hypoxia and hyperoxia
• Consider targeted temperature management (32-36°C)
• Maintain appropriate hemodynamic goals (MAP, SBP) 1

Quality Improvement Considerations

• Adherence to ACLS protocols correlates with increased ROSC 3
• Both errors of commission and omission decrease ROSC rates
• Regular simulation training for anesthesia providers on ACLS protocols

Special Circumstances

• Hypothermia: Consider modified defibrillation approach and drug administration 4
• Pregnant patients: Consider left lateral displacement and early perimortem cesarean delivery if >20 weeks gestation 1

The foundation of successful ACLS in anesthetized patients remains high-quality CPR and early defibrillation for shockable rhythms, with particular attention to anesthesia-specific causes of arrest that may require immediate intervention beyond standard ACLS protocols.