Perioperative Resuscitation and Life Support (PeRLS): Primary Goals and Recommendations
The primary goal of perioperative resuscitation is to preserve brain function and prevent secondary organ injury through early recognition and treatment of reversible causes, with most perioperative cardiac arrests having high survival rates when promptly managed due to continuous monitoring and immediate availability of trained personnel. 1
Core Principles of Perioperative Cardiac Arrest Management
Unique Context of Perioperative Arrest
Perioperative cardiac arrest differs fundamentally from other arrest scenarios because common causes—cardiovascular response to anesthesia induction, vagal responses, hypoxia, hypovolemia, and hemorrhage—are typically treatable and reversible. 1 The continuous monitoring and immediate presence of an anesthesiologist allow for instant detection and intervention, resulting in survival rates substantially higher than out-of-hospital arrests. 1
DNACPR orders should typically be suspended during the perioperative period because the reversible nature of most perioperative arrests and the immediate availability of treatment make resuscitation attempts clinically appropriate, even in patients with pre-existing do-not-resuscitate orders. 1 This suspension must be discussed and agreed upon with the patient preoperatively, with clear documentation of when the order would be reinstated. 1
Pre-operative Planning and Communication
Early pre-operative discussion with patients is mandatory to establish shared understanding about which perioperative treatments—including chest compressions and defibrillation—would be appropriate and desired. 1 This discussion must document the patient's values, preferences, wishes, and fears about their care. 1
The anaesthetist and surgical team must work together to ensure the patient fully understands the balance of risks and benefits of surgery, anaesthesia, and intensive care treatments. 1 When a patient's decision appears inconsistent with their stated values, this should trigger careful assessment of their capacity to consent. 1
Cardiovascular Management Post-Resuscitation
Hemodynamic Goals
There is insufficient evidence to recommend a specific blood pressure target after cardiac arrest—the 2024 International Consensus found no benefit from targeting mean arterial pressure above 71 mm Hg compared to 70 mm Hg or lower. 1 Four randomized trials involving 1,065 patients showed no difference in 180-day mortality (RR 1.08,95% CI 0.92-1.26) or good functional outcome (RR 0.99,95% CI 0.84-1.16) when comparing higher versus lower MAP targets. 1
Despite the lack of evidence for specific targets, hemodynamic goals should be considered as part of post-resuscitation care bundles, with individual patient factors and pre-existing comorbidities influencing decisions. 1
Vasoactive Medication Selection
For documented or suspected cardiovascular dysfunction after cardiac arrest, vasoactive drugs should be administered based on the specific hemodynamic derangement: 1
Norepinephrine (0.1-2 mcg/kg/min): For shock with low systemic vascular resistance (septic, anaphylactic, spinal, or vasodilatory) unresponsive to fluid. 1
Epinephrine (0.1-1 mcg/kg/min): Functions as inotrope and chronotrope at low doses, with pressor effects at higher doses. 1
Dobutamine (2-20 mcg/kg/min): For poor myocardial function requiring increased contractility, as it selectively affects β1- and β2-adrenergic receptors. 1
Dopamine (2-20 mcg/kg/min): Provides renal and splanchnic vasodilation at low doses, pressor effects at high doses, though doses >20 mcg/kg/min may cause excessive vasoconstriction. 1
Inodilators (milrinone, inamrinone): Augment cardiac output with minimal effect on myocardial oxygen demand, reasonable for myocardial dysfunction with increased systemic or pulmonary vascular resistance, though fluid administration may be required due to vasodilatory effects. 1
Sodium nitroprusside (0.5-8 mcg/kg/min) can be combined with inotropes when hypotension relates to poor myocardial function, reducing afterload while improving contractility. 1
Neurologic Protection Strategies
Ventilation Management
Do not provide excessive ventilation or hyperventilation routinely—hyperventilation has no benefit and may impair neurologic outcome by adversely affecting cardiac output and cerebral perfusion. 1 Intentional brief hyperventilation should only be used as temporizing rescue therapy for signs of impending cerebral herniation (sudden rise in intracranial pressure, dilated pupils unresponsive to light, bradycardia, hypertension). 1
Temperature Management
Therapeutic hypothermia (32-34°C) may be considered for children remaining comatose after resuscitation from cardiac arrest, and is reasonable for adolescents resuscitated from sudden, witnessed, out-of-hospital VF arrest. 1 While no randomized pediatric studies exist, adult data from witnessed out-of-hospital VF arrests and asphyxiated newborn data support this approach. 1
Monitor temperature continuously and treat fever (>38°C) aggressively with antipyretics and cooling devices, as fever adversely influences recovery from ischemic brain injury. 1
Avoid rewarming from 32-34°C faster than 0.5°C per 2 hours unless rapid rewarming is clinically required. 1 During hypothermia, provide sedation and neuromuscular blockade if needed to prevent shivering, recognizing this can mask seizure activity. 1
Seizure Management
Treat postischemic seizures aggressively and search for correctable metabolic causes such as hypoglycemia or electrolyte imbalance. 1
Intra-operative Decision Making
When surgical findings or patient condition change unexpectedly during operation, the pre-operative understanding of patient priorities and goals of care should guide clinical decisions by the anaesthetist and surgical team. 1
For patients brought to the operating theatre rapidly—unconscious or without capacity—the principle is to gather as much information as possible and, unless information indicates otherwise, pursue full and active treatment as far as clinically appropriate. 1
Prompt treatment of blood loss or adverse drug reactions may restore good prognosis, while outcomes from intra-operative stroke or myocardial infarction require individual assessment. 1 Pre-operative documentation of patient wishes enables clinicians to act confidently and ethically during time-critical intra-operative complications or cardiac arrest. 1
Post-operative Monitoring and Care
Essential Monitoring Parameters
Monitor heart rate, blood pressure, and urine output with frequent clinical evaluations until stable. 1 Consider 12-lead ECG to establish the cause of cardiac arrest. 1
Remove intraosseous access after alternative secure venous catheters are placed (preferably 2). 1 Monitor venous or arterial blood gas analysis, serum electrolytes, and glucose. 1
Obtain chest x-ray to evaluate endotracheal tube position, heart size, and pulmonary status. 1 Consider arterial lactate and central venous oxygen saturation to assess adequacy of tissue oxygen delivery. 1
Post-anaesthesia Care Unit Considerations
Deterioration in the post-anaesthesia care unit, ICU, or ward may be wholly or partly due to reversible elements of anaesthesia—residual drug effects or continuing analgesia effects. 1 These should be treated with reference to the recorded plan and as agreed during appropriate discussion. 1
When prognosis changes unexpectedly at the end of surgery in an unconscious patient and is now agreed to be poor, information gathered through pre-operative processes becomes invaluable for guiding subsequent decision-making and should be shared with ICU and postoperative teams. 1
Critical Pitfalls to Avoid
Never assume chest compressions for expediting drug circulation during low cardiac output (distinct from cardiac arrest) falls under a DNACPR order—this is qualitatively different from CPR. 1 Similarly, DNACPR orders do not normally exclude drugs from the cardiac arrest algorithm when used to treat bradycardia, hypotension, or arrhythmia during anaesthesia, nor do they prevent defibrillation for suddenly occurring arrhythmia. 1
Myocardial dysfunction and vascular instability commonly evolve over time following resuscitation, with an initial hyperdynamic state potentially replaced by worsening cardiac function. 1 Continuous reassessment is essential rather than assuming stable hemodynamics.
Documentation of all discussions and decisions must be clear, dated, and signed in the patient's health record and shared at the team brief. 1 Decisions should be reviewed when the patient changes their mind, when clinical condition changes, when significant time has passed, or when previous discussions were held by others. 1