What to do if a patient with a Do Not Resuscitate (DNR) order experiences cardiac arrest during colonoscopy under anesthesia?

Management of Cardiac Arrest During Colonoscopy in a Patient with DNR Order

The anesthesiologist should continue CPR and full resuscitative efforts during the intraoperative cardiac arrest, as DNR orders should typically be suspended during the perioperative period due to the high likelihood of successful resuscitation from reversible procedural causes. 1

Rationale for Continuing Resuscitation

High Success Rate of Perioperative Resuscitation

• Intraoperative cardiac arrest has substantially higher survival rates compared to other settings, making resuscitation appropriate even in patients with pre-existing DNR orders 1
• Perioperative cardiac arrests typically result from readily reversible causes including cardiovascular response to anesthesia induction, vagal responses to procedural manipulation, hypoxia, hypovolaemia, and hemorrhage 1
• The continuous monitoring and immediate presence of an anesthesiologist allow for instant detection and treatment of arrest, fundamentally changing the risk-benefit calculation 1
• Good outcomes after prolonged CPR in the operating room depend on the patient's pre-arrest condition and reversible etiology of arrest 2

Standard Practice for DNR Suspension

• It is usually appropriate to suspend a DNACPR recommendation during the perioperative period when cardiac arrest results from treatable and potentially reversible procedural causes 1
• The suspension should have been discussed and agreed upon with the patient prior to the procedure, with clear documentation in the medical record 1
• DNR orders are recommendations rather than legally binding directives, allowing clinical judgment in emergency situations 1

Immediate Actions During the Arrest

Continue Standard ACLS Protocol

• Maintain high-quality chest compressions at a rate of at least 100/minute with adequate depth (at least 2 inches in adults) 1
• Minimize interruptions in compressions and allow complete chest recoil after each compression 1
• If the patient is unconscious/unresponsive with absent or abnormal breathing, assume cardiac arrest and continue CPR 1
• The benefit of providing CPR outweighs any potential risk, as the risk of injury from CPR is low (rib/clavicle fractures 1.7%, with no visceral injuries typically reported) 1

Identify and Treat Reversible Causes

• Rapidly assess for procedure-specific causes: vagal response from colonoscopy manipulation, sedation-related cardiovascular depression, hemorrhage, or perforation 1
• Consider that bradycardia progressing to asystole can occur from vagal stimulation during gastrointestinal procedures 3
• Treat identified causes while maintaining continuous CPR 1

Post-Resuscitation Management

Documentation Requirements

• Document the cardiac arrest event, duration of CPR, interventions performed, and outcome 4
• Record the rationale for continuing resuscitation despite DNR status, citing the perioperative exception 4
• Note any discussions with the patient or surrogate decision-maker if they become available 4

Reinstate DNR Discussion

• Once the patient is stabilized and has capacity, or when surrogate decision-makers are available, discuss whether the DNR order should be reinstated 1
• Clearly document the circumstances under which the patient wants the DNR order to be brought back into force 1
• Review the DNR order as the patient's condition changes during recovery 4

Critical Distinction: What DNR Does NOT Prohibit

Interventions That Remain Appropriate

• Giving chest compressions to expedite circulation of drugs in the face of low cardiac output (distinct from cardiac arrest) is not considered CPR and is not covered by DNR orders 1
• Use of drugs from the cardiac arrest algorithm (epinephrine, atropine, antiarrhythmics) to treat bradycardia, hypotension, or arrhythmia during anesthesia is not prohibited by DNR orders 1
• Defibrillation or synchronized cardioversion for suddenly occurring arrhythmia is not prevented by advance decisions to refuse CPR 1

Common Pitfall to Avoid

The most critical error would be to withhold resuscitation based solely on the presence of a DNR order without considering the unique perioperative context. The procedural setting fundamentally changes the probability of successful resuscitation with good neurological outcome, which is a key factor that influences patients' preferences for resuscitation 5. Patients with DNR orders may not have anticipated or intended to refuse resuscitation for witnessed, monitored arrests with reversible iatrogenic causes that have high success rates 5.